GRAY MATTERS: Shared decision-making center to open in fall

Shared decision-making programs, like the one that will open here in the fall, include free booklets about health conditions and the pros and cons of different health care choices to treat those conditions, all in easy-to-understand language that is reviewed regularly and updated as necessary.

The top recommendation from a community report addressing North Coast surgery rates that more than double the rest of the state on some elective procedures will come to fruition in early fall with the opening of a shared decision-making center in Eureka.

Primary care providers will refer people to the center, the health professionals who staff it and the decision aids available on site.

Walk-ins will be accepted without referral and services will be free to people of all ages, with or without health insurance.

The goal is to give patients a place to go to get current, neutral and often quantitative information about so-called "preference-sensitive procedures," generally elective, for which there are multiple treatment options that are roughly equivalent.

"Fabulous," said Dawn Ellsbree when she heard the California HealthCare Foundation awarded a grant to support the center's development.

Ellsbree is executive director of The Headwaters Fund and a member of the group of primary care providers, surgeons and specialists, and community lay people who authored the 2013 Surgical Rate Project report and presented it to the Board of Supervisors in August 2013.

"It really validates the work we did and the importance that shared decision-making is being given on a more global level," she said.

Jay Reed, partner at Aalfs Evans and Company and another participant in the Surgical Rate Project, called news of the center "encouraging and unexpected."

"Throughout the process of examining our surgical rates, we realized what a big machine health care is and how difficult it is to make changes, so to see our efforts result in material change on a local level is a pretty neat experience," he said.

Ellsbree and Reed said the surgical rate report made shared decision-making assistance its top recommendation to help patients navigate, understand and weigh alternative treatment options within their own value systems.

"The way the system works, doctors don't have a lot of time to sit with patents to answer questions, and often times, the patient doesn't have the ability to listen to all that's being said or to form the questions right then," Reed said.

"Often, a primary care doctor is referring a patient to a specialist with the idea that the specialist will discuss options with the patient, but a specialist who gets a referral often assumes the decision has been made to do surgery," Ellsbree said.

"At the end of the day, the patients have to own it," Reed said. "They will be more satisfied with whatever treatment they go forward with when they are able to engage a little more, become better educated and then make an informed decision."

The Humboldt Del Norte Independent Practice Association and Foundation for Medical Care received the $105,000 grant for the center on June 1.

A local project team is now working with the Informed Medical Decision Foundation in Boston to develop what IPA chief executive officer Martin Love called an "innovative model" that may be used for end-of-life decisions and for "patients having conditions or needing tests or procedures which are preference sensitive."

"Shared decision-making helps patients have their desires, fears, hopes and goals weighed in the process of determining what to do," Love said. "It's been described and encouraged for at least 30 years; nevertheless, it is rarely practiced. Even the term to denote a process distinct from describing risks and benefits in acquiring patient consent for a particular surgery may be foreign to some clinicians."

Preference sensitive procedures are generally elective and were the focus of a 2011 study by Stanford University health care economist Laurence Baker.

The rates were based on where the patient resided, not where the surgery was done.

In five of the 13 procedures, one or more of Humboldt's three hospital services areas in Arcata, Eureka and Fortuna had rates greater than 150 percent of the state average.

The numbers prompted the IPA-Foundation and Aligning Forces Humboldt, a program based at Humboldt State University, to initiate the Surgical Rate Project. Three groups — community, primary care physicians and a combination group of surgeons and specialists — looked at the results in four of the five high-rate areas.

It marked the first time locally that the medical professionals invited a group from the "outside" —– the consumer community that included Reed, Ellsbree and seven others — to assess surgical rates that Humboldt County Supervisor Esther Fennell called "alarming."

For one of the measures, carotid endarterectomy, the individual rates for people living in each locale were 2 to 2.5 times as high as the state average.

Carotid endarterectomy is a procedure to remove plaque build-up in the neck arteries to prevent strokes.

Arcata, Eureka and Fortuna residents were also 1.6 to 2.6 times more likely than other Californians to have an elective coronary artery bypass graft.

According to the Centers for Disease Control, heart disease and stroke were the No. 1 and No. 3 causes of death among U.S. adults aged 65 and older in 2007, which makes those procedures more likely to be performed on that age group.

Love said the center will focus on some cardiovascular and orthopedic conditions and end-of-life decisions and will be based at the IPA office at 2662 Harris St. (across from Safeway).

Printed guides that are neutral and easy-to-read, as well as nurses and coaches, will be available at the center. The center will receive and coordinate referrals from primary care providers, but patients always have the option to skip the center, Love said.

"We believe the benefit will show itself and that use of the center will become the norm in Humboldt County," Love said.